Using qualitative research to get doctors to open up

Heart maps and tarot cards

Editor’s note: Steve Richardson is director of communications for the Qualitative Research Consultants Association, St. Paul.

Physicians are often difficult to interview deeply about their decision-making because they are literal and left-brained, busy, stressed and may not believe marketing influences them. While brilliant and insightful, some can also come off as arrogant and egotistical. They are often unable to explain their professional and emotional engagement in the disease process and treatment beyond medical training, clinical studies, comfort and habit, and sales rep inducements. However, innovative projective techniques can help to uncover physicians’ deeper beliefs and values by using symbols, priorities, memories, stories, emotions, metaphors, analogies, patient segmentations and archetypes. These techniques, including magazine scrap art, heart maps, memory storytelling and photo decks, can also be useful for other respondent types, from businesspeople to consumers, depending on the research objectives.

Qualitative Research Consultants Association (QRCA) members Pat Sabena and Nicole Sabena Feagin of Sabena Qualitative Research Services - whose award-winning ESOMAR paper, “Getting Doctors to Spill Their Guts” informed much of this article - say the setup is an important part of successful research with doctors. When each interview begins - whether focus groups, quads, triads, dyads or individual in-depth interviews - tell physicians that this research will be “unlike what they may have experienced in previous research” and encourage them to take a leap of faith that they can “tap into their creative side” by not over-thinking and by getting into the moment. While some grumble or protest that they don’t have a creative side, the research results can certainly prove otherwise.

For example, after introductions (always call physicians by their first name, not Dr. so-and-so, telling them this is for their confidentiality), launch each interview immediately into projective techniques to avoid physician-speak and/or groupthink. The conventional view that all respondents need to build trust with the interviewer before any projective techniques are introduced has not been true in Sabena Research’s experience, especially in these projects aimed at mining deeper insights. One thing to mention is how meaningful and fun other doctors have found these exercises, which helps manage expectations and challenge their competitiveness.

Work wonders

Here are some projective techniques that work wonders with physicians:

• Magazine scrap art symbolizes experiences of treating particular disease states. QRCA member Camille Carlin of Camille Carlin Qualitative Research Inc. uses magazine scrap art imagery exercises to uncover feelings and attitudes such as “the joys and challenges of being an oncologist.” For example, the oncologist is asked to look through non-medical magazines, catalogs and the Web and bring to the interview one or two images, pictures, words or phrases that best illustrate the joys and challenges of their job. This approach helps oncologists talk about their feelings of frustration, stress, anxiety and being overwhelmed; as well as feeling excited, optimistic and hopeful about the development of new medications. This exercise can be used with all types of physicians as an indirect approach to uncover their feelings and attitudes.
• Heart maps reveal physicians’ priorities by showing which diseases are close to, and far from, their own emotions - often in ways they may not have realized beforehand. This technique has physicians write down the ailments and diseases that are closest to their own heart, emotionally, using spatial nearness to a heart symbol, and rank order numbers. Why are their favorites their favorites?   What about treating those ailments or diseases gives them the most satisfaction?  Why were other conditions farther down the list? What about treating those ailments or diseases gives them less satisfaction?

In a Sabena study, internists, family/general practitioners and cardiologists ranked diabetes, high cholesterol and high blood pressure as the top three conditions they most like to treat. They explained that these medical conditions are dangerous and very prevalent in their patient populations and they now have the medications to make a significant difference in patients’ longevity and quality of life.

These same physicians rank other ailments much lower than this “big three” because some ailments seem too minor or have less clear means to achieve results, like skin problems, acid reflux and migraines. Other disorders seem too difficult for them to treat effectively, such as Alzheimer’s, multiple sclerosis and lupus. Since they often refer these patients to other specialists, this leaves them feeling out of their depth and unable to help the patients personally.

The heart map technique was beneficial in another study conducted by QRCA member Myra Summers of Focus Forward Inc. The study was partially aimed at better understanding the attitudes of general practitioners toward treating depression. In the study, Summers found that several of the doctors who derived less satisfaction from treating depression often had little mental health training and thus lacked confidence in accurately diagnosing and treating the disorder. Several also expressed frustration with some patients’ refusal to admit they are depressed, as well as patients who resist seeking counseling in conjunction with taking medication.

• Memory storytelling explores each physician’s satisfying and disappointing treatment experiences to get rich details about patient types, prescribing habits and good and bad outcomes. With this technique, the researcher asks physicians to recall everything they can about a patient suffering from a disease state that proved to be a satisfying treatment experience. How did treating this patient make them feel? They are then asked to recount the story of a patient whose treatment experience was disappointing to them.

Prior completion of the scrap art exercise and the heart map seems to stir up or rekindle memories of good and bad treatment experiences in virtually all physicians. This is in sharp contrast to how they struggle with or refuse to complete this question on a rescreener sheet in the waiting room prior to the interview. Without exception, asked now to tell the story of a satisfying and a disappointing treatment experience, physicians immediately and emotionally come up with remarkably detailed recollections, including the patient’s age, gender, race, statistics, and unique set of symptoms, treatment and outcomes.

• Sentence completions help obtain treatment metaphors and analogies. While they are in a thoughtful frame of mind after memory-based storytelling, ask physicians to perform a sentence completion exercise by borrowing analogies or metaphors from different categories or different worlds (sports, politics, movies, books, animals, foods, etc.) to describe treatment of whatever disease state is under investigation. Using such sentences, physicians come up with dozens of different and vivid metaphorical or analogous examples of relating to patients and/or choosing from the cornucopia of medications. Some examples: “Treating diabetes is like….” or “The hardest part about treating congestive heart failure is….” These metaphors and analogies provide rich fodder for future advertising themes and executions.
• Tarot cards serve as unique picture-sort stimuli for images and archetypes (but are not used as actual tarot cards for readings, just for the symbolism). In this technique, ask physicians to thumb through the cards quickly and come up with ones that describe or dramatize how they personally feel about being a doctor in the practice of medicine as it relates to a particular disease state. Once they have made a selection of one or more cards, ask them to tell a personal story about how each relates to them in this context. The researcher should be prepared for surprises and very inventive stories about what they interpret and project from the images of these cards.

Their individual choices and the stories they then tell about the cards they pick reveal archetypes of their engagement, their roles, their doubts and frustrations and their rewards, with many surprising outcomes busting myths about today’s cynical stereotypes of physicians. In a Sabena study, there were several surprising findings:

— Much less about power and arrogance: Very few chose “powerful” or despotic “ruler” cards.

— Much more about the “magic” of healing: Many identified with magic by “waving a wand,” using a “bag of tricks,” or giving a “potion” of drugs.

— Much more about saving and rescuing patients:   Many talked about feeling like the “knight in shining armor” or the “warrior.”

— Doubts about their own judgment and choices: Many cited “loneliness,” “challenge” and “frustration” in their treatment decisions.

— Acknowledgement about the role of luck: Quite a few revealed their “insecurities” about the hit-or-miss aspects of treatment.

— Considerable frustration with patients in denial or non-compliance: They feel critical of “foolish” patients who ignore the dire consequences of their risks and inaction.

— Joy and satisfaction in promoting healthy control: Ultimately, they feel truly happy and genuinely rewarded when patients comply and improve their outcomes.

In another study conducted by Summers, the tarot card technique was helpful in understanding doctors’ attitudes towards treating terminally ill patients (though Summers also does not use the cards as they are used in tarot readings). The technique revealed meaningful insight into the emotional distress a number of oncologists experience every day. Some selected the judgment card as a good representation of how they feel when dealing with terminally ill patients, as the condition forces them to evaluate their own mortality, examine how they personally feel about quality of life and struggle to help patients decide how much pain and discomfort is too much to fight. “Oncologists who seemed to feel more positively about the experience of treating terminally ill patients chose the sun and strengths cards, saying these cards remind them of the emotional rewards of relieving suffering in someone,” Summers says.

• QRCA member Suzette deVogelaere of Concepts & Strategies offers two additional techniques that have worked well for her when interviewing doctors: a bull’s-eye and photo decks. For one research project, a bull’s-eye was used to represent the ideal company. Physicians were handed a bull’s-eye drawn with three concentric rings and IDEAL written in the middle circle. They were asked to describe what would make a company ideal - in this case, one supplying vascular products. Their responses included not only products and features but also touched on everything from sales reps and corporate ethics.

With this approach, once the ideal company is defined, ask respondents who the major companies are and give them color-coded dots with the initials of the major companies to be explored. Have them place each dot on the bull’s-eye, one at a time, and discuss their reasons for the placement. In deVogelaere’s study, their responses showed their impressions of: who the competition is; each company compared to the ideal; each company vis-à-vis the competition; and what each has to do to move closer to the ideal.

The bull’s-eye can also be used as a crystal ball. Have respondents think 10 years out and describe what would define the ideal company and then have them speculate on which company will get there first and why.

Photo decks help physicians bring to the surface their feelings about different health care companies and what each represents to them. Hand respondents a stack of non-medical photos randomly pulled from magazines. The pictures should have no words on them and be as ambiguous as possible; the ambiguity of the pictures (such as a tree made out of a stalk of broccoli with a swing hanging from it) is what makes physicians - and any respondent for that matter - stretch, digging deeper for the emotions around the different brands. This stretching also generates a much richer vocabulary than ordinary conversation, which is great for creative development.

Candid and authentic

As these and other similar qualitative methods show, even the most cynical or arrogant respondents (physicians, surgeons, dentists, CEOs, IT managers, etc.) can be encouraged to be more candid and authentic in their responses. Well-structured interviews and creative stimuli help them to open up in a safe and thoughtful manner, paving the way for deeper revelations about all manner of topic areas.